Medication use in older adults receiving palliative and supportive care presents a decision problem that cannot be resolved by medication count, potentially inappropriate medication criteria, or deprescribing targets alone. Therapeutic benefit may diminish as prognosis, goals of care, functional reserve, treatment burden, and monitoring capacity change, yet medication withdrawal can also create harm when effective symptom control, prevention of near-term complications, or correction of therapeutic underuse remains clinically important. This conceptual article develops a clinical pharmacotherapy decision framework that integrates goals of care, prognosis and time-to-benefit, medication benefit–burden balance, patient-level determinants, medication-level determinants, clinician judgment, organizational capacity, and surveillance for medication-related harm. The framework treats continuation, initiation, modification, simplification, intensified monitoring, and deprescribing as alternative optimization responses rather than assuming that medication reduction is the preferred endpoint. Particular attention is given to potentially inappropriate prescribing, drug–drug interactions, prescribing cascades, medication discrepancies, administration complexity, therapeutic failure, and the division of responsibility among pharmacists, physicians, and nurses. The central proposition is that pharmacotherapy optimization in palliative and supportive care is a dynamic, context-sensitive process in which the same medication may remain appropriate, require modification, or become inappropriate as patient goals, prognosis, risk, and implementation conditions change. The framework therefore positions adverse drug event prevention within repeated clinical reassessment rather than within medication reduction alone.
